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<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><span
style='font-size:14.0pt'>BAN CHỈ ĐẠO TỔNG ĐIỀU TRA DÂN SỐ LIÊN NGÀNH</span></p>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
style='font-size:26.0pt'>PHIẾU ĐIỀU TRA DÂN SỐ LIÊN NGÀNH</span></b></p>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'>THỜI
ĐIỂM 0 GIỜ NGÀY 01/4/2016</p>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><img
width=115 height=115 id="Picture 1" src="chuan_files/image001.jpg"></p>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
style='font-size:10.0pt;font-family:"Arial-BoldMT","sans-serif"'>THÔNG TIN GHI
TRÊN PHIẾU ĐIỀU TRA ĐƯỢC GIỮ KÍN</span></b></p>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
style='font-size:10.0pt;font-family:"Arial-BoldMT","sans-serif"'>&nbsp;</span></b></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0
 style='border-collapse:collapse;border:none'>
 <tr>
  <td width=680 colspan=4 valign=top style='width:509.75pt;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoListParagraph align=center style='margin-top:3.0pt;margin-right:
  0in;margin-bottom:3.0pt;margin-left:.5in;text-align:center;text-indent:-.25in;
  line-height:normal'><b><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>A.<span
  style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp; </span></span></b><b><span
  style='font-size:12.0pt;font-family:"Arial","sans-serif"'>THÔNG TIN HỘ DÂN CƯ</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=680 colspan=4 valign=top style='width:509.75pt;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-size:1.0pt;
  font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Thành
  phố</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-family:"Arial","sans-serif"'>HÀ
  NỘI</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Quận</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-family:"Arial","sans-serif"'>CẦU
  GIẤY</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Phường</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;text-align:justify;line-height:120%'><b><span
  style='font-family:"Arial","sans-serif"'>MỸ ĐÌNH</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=680 colspan=4 valign=top style='width:509.75pt;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;text-align:justify;line-height:120%'><b><span
  style='font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Địa
  bàn điều tra</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-family:"Arial","sans-serif"'>001</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Tên
  địa bàn điều tra</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-family:"Arial","sans-serif"'>THÔN
  1</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Mã
  hộ điều tra</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-family:"Arial","sans-serif"'>10221210</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=680 colspan=4 valign=top style='width:509.75pt;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-size:1.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Tên
  chủ hộ</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><b>TRẦN
  VĂN LANG</b></span></p>
  </td>
 </tr>
 <tr>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Số
  nhân khẩu thực tế thường trú trong hộ dân cư này</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><b>3</b></span></p>
  </td>
 </tr>
 <tr>
  <td width=680 colspan=4 valign=top style='width:509.75pt;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Địa
  chỉ chi tiết của hộ:  <b>Số nhà</b> <b>2A4</b></span></p>
  </td>
 </tr>
 <tr style='height:21.3pt'>
  <td width=121 style='width:90.7pt;border:none;border-left:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:21.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><span
  style='font-family:"MS Gothic"'>☒</span> Ngõ</span></p>
  </td>
  <td width=247 style='width:185.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:21.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><b>Ngõ
  565</b> </span></p>
  </td>
  <td width=119 style='width:88.95pt;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:21.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width=193 valign=top style='width:144.6pt;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:21.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
 </tr>
 <tr style='height:25.25pt'>
  <td width=121 style='width:90.7pt;border:none;border-left:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.25pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><span
  style='font-family:"MS Gothic"'>☐</span> Nghách</span></p>
  </td>
  <td width=247 style='width:185.5pt;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:25.25pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span class=MsoPlaceholderText>Click
  here to enter text.</span></p>
  </td>
  <td width=119 style='width:88.95pt;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:25.25pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width=193 valign=top style='width:144.6pt;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.25pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
 </tr>
 <tr style='height:12.4pt'>
  <td width=121 valign=top style='width:90.7pt;border:none;border-left:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:12.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'>Đường
  phố</span></p>
  </td>
  <td width=559 colspan=3 valign=top style='width:419.05pt;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><b><span style='font-family:"Arial","sans-serif"'>Đường
  Nguyễn Trãi</span></b></p>
  </td>
 </tr>
 <tr style='height:12.4pt'>
  <td width=368 colspan=2 valign=top style='width:276.2pt;border:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:12.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><span
  style='font-family:"MS Gothic"'>☒</span> Tổ dân phố     <span
  style='font-family:"MS Gothic"'>☐</span> Thôn       <span style='font-family:
  "MS Gothic"'>☐</span> Xóm       <span style='font-family:"MS Gothic"'>☐</span>
  Ấp/bản</span></p>
  </td>
  <td width=311 colspan=2 valign=top style='width:233.55pt;border:solid windowtext 1.0pt;
  border-left:none;padding:0in 5.4pt 0in 5.4pt;height:12.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:120%'><span style='font-family:"Arial","sans-serif"'><b>Tổ
  dân phố số</b> <b>12</b></span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
style='font-size:10.0pt;font-family:"Arial-BoldMT","sans-serif"'>&nbsp;</span></b></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0
 style='border-collapse:collapse;border:none'>
 <tr>
  <td width=695 colspan=3 valign=top style='width:521.05pt;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
  style='font-size:12.0pt;font-family:"Arial","sans-serif"'>KÝ XÁC NHẬN</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=695 colspan=3 valign=top style='width:521.05pt;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-size:1.0pt;
  font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=257 valign=top style='width:192.45pt;border:none;border-left:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-size:10.0pt;
  font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
  <td width=201 valign=top style='width:150.8pt;border:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
  style='font-family:"Arial","sans-serif"'>HỌ VÀ TÊN</span></b></p>
  </td>
  <td width=237 valign=top style='width:177.8pt;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><b><span
  style='font-family:"Arial","sans-serif"'>CHỮ KÝ</span></b></p>
  </td>
 </tr>
 <tr>
  <td width=257 valign=top style='width:192.45pt;border:none;border-left:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>NGƯỜI
  CUNG CẤP THÔNG TIN</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width=201 valign=top style='width:150.8pt;border:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='position:absolute;
  z-index:251643904;margin-left:6px;margin-top:44px;width:188px;height:1px'><img
  width=188 height=1 src="chuan_files/image002.png"></span></p>
  </td>
  <td width=237 valign=top style='width:177.8pt;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='position:absolute;
  z-index:251650048;margin-left:25px;margin-top:44px;width:188px;height:1px'><img
  width=188 height=1 src="chuan_files/image002.png"></span></p>
  </td>
 </tr>
 <tr>
  <td width=257 valign=top style='width:192.45pt;border:none;border-left:solid windowtext 1.0pt;
  padding:25pt 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>ĐIỀU
  TRA VIÊN</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width=201 valign=top style='width:150.8pt;border:none;padding:25pt 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='position:absolute;
  z-index:251645952;margin-left:5px;margin-top:22px;width:188px;height:1px'><img
  width=188 height=1 src="chuan_files/image002.png"></span></p>
  </td>
  <td width=237 valign=top style='width:177.8pt;border:none;border-right:solid windowtext 1.0pt;
  padding:25pt 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='position:absolute;
  z-index:251652096;margin-left:24px;margin-top:22px;width:188px;height:1px'><img
  width=188 height=1 src="chuan_files/image002.png"></span></p>
  </td>
 </tr>
 <tr>
  <td width=257 valign=top style='width:192.45pt;border:none;border-left:solid windowtext 1.0pt;
  padding:25pt 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>TỔ
  TRƯỞNG ĐIỀU TRA </span></p>
  </td>
  <td width=201 valign=top style='width:150.8pt;border:none;padding:25pt 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='position:absolute;
  z-index:251824128;margin-left:5px;margin-top:22px;width:188px;height:1px'><img
  width=188 height=1 src="chuan_files/image002.png"></span></p>
  </td>
  <td width=237 valign=top style='width:177.8pt;border:none;border-right:solid windowtext 1.0pt;
  padding:25pt 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='position:absolute;
  z-index:251825152;margin-left:24px;margin-top:22px;width:188px;height:1px'><img
  width=188 height=1 src="chuan_files/image002.png"></span></p>
  </td>
 </tr>
 <tr>
  <td width=257 valign=top style='width:192.45pt;border-top:none;border-left:
  solid windowtext 1.0pt;border-bottom:solid windowtext 1.0pt;border-right:
  none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><span style='font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width=201 valign=top style='width:150.8pt;border:none;border-bottom:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;text-align:justify;line-height:normal'><b><span
  style='font-size:10.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
  <td width=237 valign=top style='width:177.8pt;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;text-align:justify;line-height:normal'><b><span
  style='font-size:10.0pt;font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
 </tr>
</table>

<p style="page-break-after:always;"></p>
<p style="padding-top:20px;"></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0
 style='border-collapse:collapse;border:none; width:100%;'>
 <tr>
  <td width=340 valign=top style='width:254.85pt;border:dotted windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-family:"Arial","sans-serif"'>HỘ
  ĐIỀU TRA SỐ: 10221210 </span></b></p>
  </td>
  <td width=340 valign=top style='width:254.9pt;border:dotted windowtext 1.0pt;
  border-left:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:right;line-height:normal'><b><span
  style='font-family:"Arial","sans-serif"'>CÔNG DÂN SỐ: 001</span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:3.0pt;line-height:107%'>&nbsp;</span></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0
 style='border-collapse:collapse;border:none;width:100%;'>
 <tr>
  <td valign=top style='width:100%;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoListParagraph align=center style='margin-top:3.0pt;margin-right:
  0in;margin-bottom:3.0pt;margin-left:.5in;text-align:center;text-indent:-.25in;
  line-height:normal'><b><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>B.<span
  style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp; </span></span></b><b><span
  style='font-size:12.0pt;font-family:"Arial","sans-serif"'>THÔNG TIN THÀNH
  VIÊN TRONG HỘ</span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:3.0pt;line-height:107%'>&nbsp;</span></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0 width="100%"
 style='width:100.0%;border-collapse:collapse;border:none'>
 <tr style='height:.15in'>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt;height:.15in'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><b><span style='font-size:4.0pt;line-height:120%;
  font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
  <td width="94%" colspan=4 valign=top style='width:94.36%;border:solid windowtext 1.0pt;
  border-left:none;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt;height:.15in'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>THÔNG
  TIN CƯ DÂN</span></b></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border-top:none;border-left:
  solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>1.</span></p>
  </td>
  <td width="23%" rowspan=2 valign=top style='width:23.6%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Họ
  tên thành viên hộ (Bắt đầu từ chủ hộ)</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>HỌ:
  <b>TRẦN</b>      TÊN ĐỆM: <b>VĂN</b>       TÊN: <b>LANG</b></span></p>
  </td>
 </tr>
 <tr style='height:19.0pt'>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:19.0pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:19.0pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa]……………………………………………………………….............</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>2.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Quan
  hệ với chủ hộ</span></p>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>[Chỉnh sửa]</span></p>
  </td>
  <td width="35%" valign=top style='width:35.38%;border:none;border-bottom:
  solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Chủ
  hộ</span></b></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Chủ
  hộ........................... 1 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Vợ/chồng
  ...................... 2 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Con
  đẻ........................... 3 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  </td>
  <td width="35%" colspan=2 valign=top style='width:35.38%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Cháu
  nội/ngoại….. ........... 4 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Bố/mẹ
  .............................. 5 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Quan
  hệ khác…. ..............6 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>3.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Hiện
  trạng của cư dân</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Mất tích…. 1 <span
  style='font-family:"MS Gothic"'>☐</span>        Đã chết…. 2 <span
  style='font-family:"MS Gothic"'>☐</span>           Đã chuyển đi…. 3 <span
  style='font-family:"MS Gothic"'>☐</span>  </span></p>
  <p class=MsoNormal style='margin:0px 0px 0px 0px;'>
	<img style="margin-bottom:7px; margin-left:22px;" width=45 height=26 src="chuan_files/image005.png"></span>
	<img style="margin-bottom:11px; margin-left:-10px;" width=26 height=22 src="chuan_files/image004.png"></span>
	<img style="margin-bottom:4px; margin-left:55px;" width=63 height=29  src="chuan_files/image006.png"></span>
	<img style="margin-bottom:0px; margin-left:35px;" width=125 height=33 src="chuan_files/image003.png"></span>
  </p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>4.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Giới
  tính cư dân</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><i><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'><b><span
  style='font-style:normal'>NAM</span></b>                     </span></i><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa]  NAM … 1 <span style='font-family:"MS Gothic"'>☐</span>      NỮ … 2 <span
  style='font-family:"MS Gothic"'>☐</span>     KXĐ … 3 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border-top:none;border-left:
  solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>5.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  sinh dương lịch</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>NGÀY:
  <b>04</b>     THÁNG: <b>04</b>           NĂM:  <b>1983</b></span></p>
  </td>
 </tr>
 <tr style='height:16.1pt'>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:16.1pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.1pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>[Chỉnh sửa]</span></p>
  </td>
  <td width="44%" colspan=2 valign=top style='width:44.44%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.1pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  __ __ Tháng __ __ Năm __ __ __ __</span></p>
  </td>
  <td width="26%" valign=top style='width:26.32%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.1pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Năm
  âm: …………………..</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>KXĐ
  … 3 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border-top:none;border-left:
  solid windowtext 1.0pt;border-bottom:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>6.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>a.
  Nơi đăng ký khai sinh</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>XÃ: 
  <b>VĂN QUÁN </b>     HUYỆN: <b>HÀ ĐÔNG</b>     TỈNH: <b>HÀ TÂY</b></span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa] Xã: …………..Huyện: ………………….Tỉnh: ……………………</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>b.
  Nơi đăng ký chi tiết</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>c.
  Giấy khai sinh</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>………………………………………………………………………………….......</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số:
  ……….Quyển: ………. Ngày__ __Tháng__ __ Năm __ __ __ __</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>7.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Quê
  quán</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Xã:
  ……………..Huyện: …………………………..Tỉnh: …………...................</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>8.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Dân
  tộc</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><i><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'><b><span
  style='font-style:normal'>KINH</span></b>                    </span></i><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa] Tên dân tộc: …………………………..............</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>9.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Tôn
  giáo</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Không
  tôn giáo … 01 <span style='font-family:"MS Gothic"'>☐</span>           Tên
  tôn giáo: ………………………………….</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>10.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Quốc
  tịch</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><i><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'><b><span
  style='font-style:normal'>VIỆT NAM</span></b>           </span></i><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa] Tên quốc tịch: …………………………………..</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" rowspan=2 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>11.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Thông
  tin giấy CMND</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND: <b>11174408632</b>  Ngày cấp: <b>11/2/2002</b>  Nơi cấp: <b>CA Hà Nội</b></span></p>
  </td>
 </tr>
 <tr>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>[Chỉnh sửa]</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:7.0pt;line-height:120%;font-family:"Arial","sans-serif"'>CÁC
  CHỮ VIẾT TẮT</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:8.3pt;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:6.0pt;line-height:120%;font-family:"Arial","sans-serif"'>CMND
  – CHỨNG MINH NHÂN DÂN</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND: __ __ __ __ __ __ __ __ __ __ __ __</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  cấp __ __ Tháng cấp __ __ Năm cấp __ __ __ __</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nơi
  cấp: …………………………………………………………………………….</span></p>
  </td>
 </tr>
 <tr style='height:47.7pt'>
  <td width="5%" rowspan=3 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:47.7pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>12.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:47.7pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>a.
  Địa chỉ thường trú</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:47.7pt'>
	<table cellpadding="0" cellspacing="0">
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Giống địa chỉ hộ … 1 <span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=64 height=28 src="chuan_files/image007.png"/></td>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Khác địa chỉ hộ nhà …2 <span style='font-family:"MS Gothic"'>☐</span></span>
			</td>
			<td><img width=104 height=26 src="chuan_files/image008.png"></td>
		</tr>
	</table>

  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>………………………………………………………………………………............</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Xã:
  ……………..Huyện: …………………………..Tỉnh: …………...................</span></p>
  </td>
 </tr>
 <tr style='height:65.05pt'>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:65.05pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>b.Thông
  tin sổ hộ khẩu thường trú</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:65.05pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  sổ hộ khẩu: ……………….Ngày cấp _ _ Tháng cấp _ _ Năm cấp _ _ _ _</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  chuyển đến hộ: Ngày _ _ Tháng _ _ Năm _ _ _ _</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nơi
  thường trú trước khi chuyển đến: </span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Xã:
  ……………….Huyện: ………………..…………….Tỉnh: …………............</span></p>
  </td>
 </tr>
 <tr style='height:75.65pt'>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:75.65pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>c.
  Thông tin chủ hộ trong sổ hộ khẩu</span></p>
  </td>
  <td width="70%" colspan=3 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:75.65pt'>
  
	<table cellpadding="0" cellspacing="0">
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Là chủ hộ dân cư ... 1 <span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=63 height=28 src="chuan_files/image010.png"/></td>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Khác chủ hộ dân cư ... 2 <span style='font-family:"MS Gothic"'>☐</span></span>
			</td>
			<td><img width=103 height=26 src="chuan_files/image009.png"></td>
		</tr>
	</table>
	
 
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Tên
  chủ hộ: ……………………………………………………</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  sinh chủ hộ _ _ Tháng sinh _ _ Năm sinh _ _ _ _</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Dân
  tộc chủ hộ:    Kinh …. 1<span style='font-family:"MS Gothic"'>☐</span>       
  Dân tộc khác: ……………………………</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:4.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND chủ hộ: __ __ __ __ __ __ __ __ __ __ __ __</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>13.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nơi
  ở hiện tại</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'>
  
	<table cellpadding="0" cellspacing="0">
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Giống địa chỉ thường trú …1 <span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=59 height=28 src="chuan_files/image012.png"/></td>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Khác địa chỉ …2 <span style='font-family:"MS Gothic"'>☐</span></span>
			</td>
			<td><img width=106 height=26 src="chuan_files/image011.png"></td>
		</tr>
	</table>	
  </p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>…………………………………………………………………………………........</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Xã:
  ………………..….Huyện: ………………..…….Tỉnh: …………..................</span></p>
  </td>
 </tr>
 <tr style='height:49.3pt'>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:49.3pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>14.</span></p>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:49.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Thông
  tin hộ chiếu</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:49.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Loại
  hộ chiếu: Phổ thông … 1 <span style='font-family:"MS Gothic"'>☐</span>    
  Công vụ … 2 <span style='font-family:"MS Gothic"'>☐</span>       Ngoại giao …
  3 <span style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  cấp hộ chiếu: Ngày cấp _ _ Tháng cấp _ _ Năm cấp _ _ _ _</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nơi
  cấp hộ chiếu: …………………………………………………………………</span></p>
  </td>
 </tr>
</table>

<p style="page-break-after:always;"></p>
<p style="padding-top:20px;"></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0
 style='border-collapse:collapse;border:none; width:100%;'>
 <tr>
  <td width=340 valign=top style='width:254.85pt;border:dotted windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-family:"Arial","sans-serif"'>HỘ
  ĐIỀU TRA SỐ: 10221210 </span></b></p>
  </td>
  <td width=340 valign=top style='width:254.9pt;border:dotted windowtext 1.0pt;
  border-left:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:right;line-height:normal'><b><span
  style='font-family:"Arial","sans-serif"'>CÔNG DÂN SỐ: 001</span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:2.0pt;line-height:107%'>&nbsp;</span></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0 width="100%"
 style='width:100.0%;border-collapse:collapse;border:none'>
 <tr style='height:.15in'>
  <td width="5%" valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt;height:.15in'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><b><span style='font-size:4.0pt;line-height:120%;
  font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
  <td width="94%" colspan=8 valign=top style='width:94.36%;border:solid windowtext 1.0pt;
  border-left:none;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt;height:.15in'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><b><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>THÔNG TIN CƯ DÂN</span></b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'> </span></p>
  </td>
 </tr>
 
 
 <tr style='height:16.35pt'>
  <td width="5%" rowspan=4 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>15.</span></p>
  </td>
  <td width="23%" rowspan=4 valign=top style='width:23.6%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Trình
  độ học vấn</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:7.0pt;line-height:120%;font-family:"Arial","sans-serif"'>CÁC
  CHỮ VIẾT TẮT</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:8.3pt;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:6.0pt;line-height:120%;font-family:"Arial","sans-serif"'>THCS
  - TRUNG HỌC CƠ SỞ</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:8.3pt;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:6.0pt;line-height:120%;font-family:"Arial","sans-serif"'>THPT
  - TRUNG HỌC PHỔ THÔNG</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:8.3pt;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:6.0pt;line-height:120%;font-family:"Arial","sans-serif"'>CN
  - CHUYÊN NGHIỆP</span></p>
  </td>
  <td width="16%" valign=top style='width:16.64%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Mầm non ……..</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>1 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>THPT ……………</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>5 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Cao đẳng…</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'> 9 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr style='height:16.35pt'>
  <td width="16%" valign=top style='width:16.64%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Tiểu học ………</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>2 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Trung cấp nghề…</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>6 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Đại học……</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>10 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr style='height:16.35pt'>
  <td width="16%" valign=top style='width:16.64%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>THCS …………</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>3 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Trung cấp CN…..</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>7 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Thạc sỹ……</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>11 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr style='height:16.35pt'>
  <td width="16%" valign=top style='width:16.64%;border:none;border-bottom:
  solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Sơ cấp nghề …</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;border-bottom:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>4 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Cao đẳng nghề….</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;border-bottom:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>8 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;border-bottom:
  solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Tiến sỹ……</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>12 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr style='height:16.35pt'>
  <td width="5%" rowspan=3 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>16.</span></p>
  </td>
  <td width="23%" rowspan=3 valign=top style='width:23.6%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Trình
  độ chuyên môn kỹ thuật</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:7.0pt;line-height:120%;font-family:"Arial","sans-serif"'>CÁC
  CHỮ VIẾT TẮT</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:8.3pt;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:6.0pt;line-height:120%;font-family:"Arial","sans-serif"'>CN
  - CHUYÊN NGHIỆP</span></p>
  </td>
  <td width="16%" valign=top style='width:16.64%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Chưa đào tạo ..</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>1 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Trung cấp CN…..</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>5 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Đại học……</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'> 9 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr style='height:16.35pt'>
  <td width="16%" valign=top style='width:16.64%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Sơ cấp nghề …</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>2 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Cao đẳng nghề …</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>6 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;padding:0in 5.4pt 0in 5.4pt;
  height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Thạc sỹ……</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>10 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr style='height:16.35pt'>
  <td width="16%" valign=top style='width:16.64%;border:none;border-bottom:
  solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Trung cấp nghề </span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;border-bottom:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>3 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="18%" colspan=2 valign=top style='width:18.08%;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Cao đẳng………..</span></p>
  </td>
  <td width="6%" valign=top style='width:6.94%;border:none;border-bottom:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>7 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
  <td width="13%" valign=top style='width:13.88%;border:none;border-bottom:
  solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Tiến sỹ……</span></p>
  </td>
  <td width="8%" valign=top style='width:8.28%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:16.35pt'>
  <p class=MsoNormal style='margin-top:2.0pt;margin-right:0in;margin-bottom:
  2.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>11 <span style='font-family:
  "MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" rowspan=2 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>17.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>a.Tình
  trạng việc làm</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'>
	
	<table cellpadding="0" cellspacing="0">
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Chưa đến tuổi đi làm .. 1<span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=66 height=28 src="chuan_files/image013.png"/></td>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>KXĐ ………………3 <span style='font-family:"MS Gothic"'>☐</span></span>
			</td>
			<td><img width=63 height=28 src="chuan_files/image014.png"></td>
		</tr>
		
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Đang thất nghiệp ……. 2<span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=63 height=28 src="chuan_files/image014.png"/></td>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'> Đang đi làm ……...4 <span style='font-family:"MS Gothic"'>☐</span></span>
			</td>
			<td><img width=101 height=26 src="chuan_files/image016.png"></td>
		</tr>
		
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Hết tuổi đi làm ………. 3<span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=62 height=28 src="chuan_files/image015.png"/></td>
			<td></td>
			<td></td>
		</tr>
	</table>
	</p>
  </td>
 </tr>
 <tr>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>b.
  Thông tin công việc</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nghề
  nghiệp: ………………………………………………………………………….</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Cơ
  quan, nơi làm việc: ……………………………………………………………….</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>…………………………………………………………………………………………..</span></p>
  </td>
 </tr>
 <tr style='height:14.35pt'>
  <td width="5%" rowspan=4 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:14.35pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>18.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:14.35pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Thông
  tin về y tế</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:14.35pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
 </tr>
 <tr style='height:18.15pt'>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.15pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>a. Nhóm máu cư dân</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:18.15pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nhóm
  A …1<span style='font-family:"MS Gothic"'>☐</span>    Nhóm B …2<span
  style='font-family:"MS Gothic"'>☐</span>          Nhóm AB …3<span
  style='font-family:"MS Gothic"'>☐</span>      Nhóm O …4<span
  style='font-family:"MS Gothic"'>☐</span>  </span></p>
  </td>
 </tr>
 <tr style='height:12.75pt'>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:12.75pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>b. Bệnh hiểm nghèo</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.75pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>………………………………………………………………………………..</span></p>
  </td>
 </tr>
 <tr style='height:22.5pt'>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:22.5pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>c. Tình trạng khuyết tật</span></p>
  </td>
  <td width="31%" colspan=3 valign=top style='width:31.88%;border:none;
  border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:22.5pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'><b>NA</b>        
                 </span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa]</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>  Khuyết
  tật vận động …...1 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>  Khuyết
  tật nghe, nói……2 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>  Khuyết
  tật nhìn …………3 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  </td>
  <td width="38%" colspan=4 valign=top style='width:38.88%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:22.5pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'> Khuyết
  tật thần kinh, tâm thần……4 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'> Khuyết
  tật trí tuệ………………...…5 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'> Khuyết
  tật khác ……………………6 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  </td>
 </tr>
 <tr style='height:25.35pt'>
  <td width="5%" rowspan=4 valign=top style='width:5.64%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:25.35pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:center;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>19.</span></p>
  </td>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.35pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Thông
  tin về Bảo hiểm </span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.35pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
 </tr>
 <tr style='height:25.3pt'>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.3pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>a. Bảo hiểm xã hội</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Có
  tham gia ……1 <span style='font-family:"MS Gothic"'>☐</span>      Không tham
  gia …..2 <span style='font-family:"MS Gothic"'>☐</span>      KXĐ……3 <span
  style='font-family:"MS Gothic"'>☐</span>          </span></p>
  </td>
 </tr>
 <tr style='height:25.3pt'>
  <td width="23%" valign=top style='width:23.6%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.3pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>b. Bảo hiểm thất nghiệp</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:25.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Có
  tham gia ……1 <span style='font-family:"MS Gothic"'>☐</span>      Không tham
  gia …..2 <span style='font-family:"MS Gothic"'>☐</span>      KXĐ……3 <span
  style='font-family:"MS Gothic"'>☐</span>          </span></p>
  </td>
 </tr>
 <tr style='height:25.3pt'>
  <td width="23%" valign=top style='width:23.6%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.3pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:0in;margin-left:0in;margin-bottom:.0001pt;text-align:right;
  line-height:120%'><span style='font-size:10.0pt;line-height:120%;font-family:
  "Arial","sans-serif"'>c. Bảo hiểm y tế</span></p>
  </td>
  <td width="70%" colspan=7 valign=top style='width:70.76%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:25.3pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  0in;margin-left:0in;margin-bottom:.0001pt;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Có
  tham gia ……1 <span style='font-family:"MS Gothic"'>☐</span>      Không tham
  gia …..2 <span style='font-family:"MS Gothic"'>☐</span>      KXĐ……3 <span
  style='font-family:"MS Gothic"'>☐</span>          </span></p>
  </td>
 </tr>

 
 
 <tr style='height:20.95pt'>
  <td width="5%" rowspan=5 valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:20.95pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>20.</span></p>
  </td>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:20.95pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Thông tin về cha</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:20.95pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Họ
  tên: <b>TRẦN VĂN A</b></span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa]: …………………………………………………………………</span></p>
  </td>
 </tr>
 <tr style='height:18.95pt'>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.95pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  tháng năm sinh cha</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:18.95pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>01/01/1954
  </span></b><span style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa] Ngày sinh _ _ Tháng sinh _ _ Năm sinh _ _ _ _</span></p>
  </td>
 </tr>
 <tr style='height:12.85pt'>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:12.85pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Dân
  tộc cha</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.85pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Kinh
  ….…….1<span style='font-family:"MS Gothic"'>☐</span>     Dân tộc khác:
  ……………………</span></p>
  </td>
 </tr>
 <tr style='height:11.8pt'>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:11.8pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Quốc
  tịch cha</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:11.8pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Việt
  Nam …. 1<span style='font-family:"MS Gothic"'>☐</span>     Quốc tịch khác:
  ………………….</span></p>
  </td>
 </tr>
 <tr style='height:18.45pt'>
  <td width="29%" valign=top style='width:29.72%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.45pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND cha</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.45pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>__
  __ __ __ __ __ __ __ __ __ __ __</span></p>
  </td>
 </tr>
 <tr style='height:20.95pt'>
  <td width="5%" rowspan=5 valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt;height:20.95pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>21.</span></p>
  </td>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:20.95pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Thông tin về mẹ</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:20.95pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Họ
  tên: <b>NGUYỄN THỊ A</b></span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa]: …………………………………………………………………</span></p>
  </td>
 </tr>
 <tr style='height:18.95pt'>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.95pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  tháng năm sinh mẹ</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:18.95pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>01/01/1954
  </span></b><span style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>[Chỉnh
  sửa] Ngày sinh _ _ Tháng sinh _ _ Năm sinh _ _ _ _</span></p>
  </td>
 </tr>
 <tr style='height:12.85pt'>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:12.85pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Dân
  tộc mẹ</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:12.85pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Kinh
  ….……..1<span style='font-family:"MS Gothic"'>☐</span>     Dân tộc khác:
  ……………………</span></p>
  </td>
 </tr>
 <tr style='height:11.8pt'>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:11.8pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Quốc
  tịch mẹ</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:11.8pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Việt
  Nam …. 1<span style='font-family:"MS Gothic"'>☐</span>     Quốc tịch khác:
  ………………….</span></p>
  </td>
 </tr>
 <tr style='height:18.45pt'>
  <td width="29%" valign=top style='width:29.72%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.45pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND mẹ</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt;height:18.45pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>__
  __ __ __ __ __ __ __ __ __ __ __</span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.0%;border-top:none;border-left:solid windowtext 1.0pt;
  border-bottom:none;border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>21.</span></p>
  </td>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>a. Người đại diện hợp pháp</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  
	<table cellpadding="0" cellspacing="0">
		<tr>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Có ….…….1<span
  style='font-family:"MS Gothic"'>☐</span></span></td>
			<td><img width=75 height=28 src="chuan_files/image018.png"/></td>
			<td><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Không ….…….2<span style='font-family:"MS Gothic"'>☐</span></span>
			</td>
			<td><img width=75 height=28 src="chuan_files/image017.png"></td>
		</tr>
	</table>
	
  </td>
 </tr>
 <tr>
  <td width="5%" rowspan=2 valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>b.
  Loại người đại diện hợp pháp</span></p>
  </td>
  <td width="29%" colspan=3 valign=top style='width:29.84%;border:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Người
  giám hộ ……….1<span style='font-family:"MS Gothic"'>☐</span>          </span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Cha,
  mẹ nuôi …………2<span style='font-family:"MS Gothic"'>☐</span>     </span></p>
  </td>
  <td width="35%" colspan=4 valign=top style='width:35.44%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Đại
  diện cơ sở nuôi dưỡng …..3<span style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Khác
  ………………….………….4<span style='font-family:"MS Gothic"'>☐</span></span></p>
  </td>
 </tr>
 <tr>
  <td width="29%" valign=top style='width:29.72%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>c. Thông tin về người đại
  diện hợp pháp</span></p>
  </td>
  <td width="65%" colspan=7 valign=top style='width:65.28%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Họ
  và tên: …………………………………………………………………..</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  sinh __ __ Tháng sinh __ __ Năm sinh __ __ __ __</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Dân tộc:       Kinh ….…….1<span
  style='font-family:"MS Gothic"'>☐</span>      Dân tộc khác: …………………………..</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Quốc tịch:    Việt Nam .… 1<span
  style='font-family:"MS Gothic"'>☐</span>      Quốc tịch khác: ………………………..</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND: __ __ __ __ __ __ __ __ __ __ __ __</span></p>
  </td>
 </tr>
 
</table>

<p style="page-break-after:always;"></p>
<p style="padding-top:20px;"></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0
 style='border-collapse:collapse;border:none;width:100%;'>
 <tr>
  <td width=340 valign=top style='width:254.85pt;border:dotted windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-family:"Arial","sans-serif"'>HỘ
  ĐIỀU TRA SỐ: 10221210 </span></b></p>
  </td>
  <td width=340 valign=top style='width:254.9pt;border:dotted windowtext 1.0pt;
  border-left:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=right style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:right;line-height:normal'><b><span
  style='font-family:"Arial","sans-serif"'>CÔNG DÂN SỐ: 001</span></b></p>
  </td>
 </tr>
</table>

<p class=MsoNormal><span style='font-size:1.0pt;line-height:107%'>&nbsp;</span></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0 width="100%"
 style='width:100.0%;border-collapse:collapse;border:none'>
 <tr>
  <td width="5%" valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
  <td width="95%" colspan=3 valign=top style='width:95.0%;border:solid windowtext 1.0pt;
  border-left:none;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-size:10.0pt;
  font-family:"Arial","sans-serif"'>THÔNG TIN QUAN HỆ GIA ĐÌNH</span></b></p>
  </td>
 </tr>
 
 <tr>
  <td width="5%" rowspan=4 valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>22.</span></p>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>a. Tình trạng hôn nhân</span></p>
  </td>
  <td width="65%" colspan=2 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Độc
  thân …1 <span style='font-family:"MS Gothic"'>☐</span>   Đang kết hôn …..2<span
  style='font-family:"MS Gothic"'>☐</span>     Ly hôn….…3<span
  style='font-family:"MS Gothic"'>☐</span>      KXĐ…4<span style='font-family:
  "MS Gothic"'>☐</span>  </span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  0.0pt;margin-left:0in;text-align:justify;line-height:120%'>
	  <img width=62 height=26 src="chuan_files/image019.png" style="margin-left:28px;">
	  <img width=84 height=27 src="chuan_files/image020.png" style="margin-left:48px;">
	  <img width=87 height=29 src="chuan_files/image021.png" style="margin-left:20px;">
	  <img width=62 height=26 src="chuan_files/image022.png" style="margin-left:20px;">
  </p>
  </td>
 </tr>
 <tr>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>b. Thông tin vợ/chồng</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="65%" colspan=2 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Họ
  và tên vợ/chồng: ……………………………………………………………</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  sinh __ __ Tháng sinh __ __ Năm sinh __ __ __ __</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Dân tộc:       Kinh ….…….1<span
  style='font-family:"MS Gothic"'>☐</span>      Dân tộc khác: …………………………..</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Quốc tịch:    Việt Nam .… 1<span
  style='font-family:"MS Gothic"'>☐</span>      Quốc tịch khác: ………………………..</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  CMND: __ __ __ __ __ __ __ __ __ __ __ __</span></p>
  </td>
 </tr>
 <tr>
  <td width="29%" valign=top style='width:29.72%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>c. Thông tin giấy kết hôn</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></p>
  </td>
  <td width="65%" colspan=2 valign=top style='width:65.28%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số/quyển
  số Giấy chứng nhận đăng ký kết hôn: …………………………</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  đăng ký kết hôn: ngày _ _ tháng_ _ năm_ _ _ _</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nơi
  đăng ký kết hôn:  Xã: ………………………………………………………</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Huyện:
  ………………..………………….Tỉnh: ………….............................</span></p>
  </td>
 </tr>
 <tr>
  <td width="29%" valign=top style='width:29.72%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>d. Thông tin giấy ly hôn</span></p>
  </td>
  <td width="65%" colspan=2 valign=top style='width:65.28%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Số
  quyết định ly hôn: ………………………………………………………..</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  quyết định ly hôn: ngày _ _ tháng_ _ năm_ _ _ _</span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Cấp
  Toà án công nhận: TW ....01 <span style='font-family:"MS Gothic"'>☐</span>   Tỉnh....02<span
  style='font-family:"MS Gothic"'>☐</span>   Huyện....03 <span
  style='font-family:"MS Gothic"'>☐</span></span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Huyện:
  ………..………………….Tỉnh: …………......................................</span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'><span
style='font-size:6.0pt'>&nbsp;</span></p>

<table class=MsoTableGrid border=1 cellspacing=0 cellpadding=0 width="100%"
 style='width:100.0%;border-collapse:collapse;border:none'>
 <tr>
  <td width="5%" valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
  margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:120%'><b><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>&nbsp;</span></b></p>
  </td>
  <td width="95%" colspan=3 valign=top style='width:95.0%;border:solid windowtext 1.0pt;
  border-left:none;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:3.0pt;margin-right:0in;margin-bottom:
  3.0pt;margin-left:0in;line-height:normal'><b><span style='font-size:10.0pt;
  font-family:"Arial","sans-serif"'>THÔNG TIN CHẾT/MẤT TÍCH</span></b></p>
  </td>
 </tr>
 <tr>
  <td width="5%" rowspan=2 valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>23.</span></p>
  </td>
  <td width="24%" valign=top style='width:24.14%;border:none;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Ngày chết</span></p>
  </td>
  <td width="70%" colspan=2 valign=top style='width:70.86%;border:none;
  border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  __ __ Tháng __ __ Năm __ __ __ __</span></p>
  </td>
 </tr>
 <tr>
  <td width="24%" valign=top style='width:24.14%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=right style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:right;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Nguyên
  nhân chết</span></p>
  </td>
  <td width="35%" valign=top style='width:35.42%;border:none;border-bottom:
  solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Bệnh
  tật ………………..…...1 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Tai
  nạn lao động …………..2 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Tai
  nạn giao thông …….…..3 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  </td>
  <td width="35%" valign=top style='width:35.44%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Tai
  nạn khác ………….…. 1 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Khác
  ………..………….….4 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>KXĐ
  ………..………….…. 5 <span style='font-family:"MS Gothic"'>☐</span>   </span></p>
  </td>
 </tr>
 <tr>
  <td width="5%" valign=top style='width:5.0%;border:solid windowtext 1.0pt;
  border-top:none;padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal align=center style='margin-top:1.0pt;margin-right:0in;
  margin-bottom:1.0pt;margin-left:0in;text-align:center;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>24.</span></p>
  </td>
  <td width="24%" valign=top style='width:24.14%;border-top:none;border-left:
  none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;line-height:120%'><span style='font-size:10.0pt;
  line-height:120%;font-family:"Arial","sans-serif"'>Ngày mất tích</span></p>
  </td>
  <td width="70%" colspan=2 valign=top style='width:70.86%;border-top:none;
  border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt;
  padding:0in 5.4pt 0in 5.4pt'>
  <p class=MsoNormal style='margin-top:1.0pt;margin-right:0in;margin-bottom:
  1.0pt;margin-left:0in;text-align:justify;line-height:120%'><span
  style='font-size:10.0pt;line-height:120%;font-family:"Arial","sans-serif"'>Ngày
  __ __ Tháng __ __ Năm __ __ __ __</span></p>
  </td>
 </tr>
</table>

<p class=MsoNormal align=center style='margin-top:3.0pt;margin-right:0in;
margin-bottom:3.0pt;margin-left:0in;text-align:center;line-height:normal'>&nbsp;</p>

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